Volunteer Application - Hope Hospice and Palliative Care

Name of Applicant*

Birthday (for birthday card list only)

Address*

Address Number Street City State Zip

Home Phone

Cell Phone*

Employer

Occupation*

Can receive calls at work

Yes
No
Emergency Only

Person to be notified in an emergency

Name*

Phone*

Address*

Address Number Street City State Zip

Education/Special Training

Work Experience

Two Personal References (excluding family members) Please provide a complete address, as references are verified by mail.

Reference #1

Name*

Phone*

Address*

Address Number Street City State Zip

Reference #2

Name*

Phone*

Address*

Address Number Street City State Zip

Identified Area of Interest (non-patient does not require 30 hours education course)

Patient/Family Care*

Bereavement*

Non-Patient Services*

Do you know a language other than English?*

Yes
No

Language

Speak
Read
Write

Language

Speak
Read
Write

Other special services: (manicurist, hairdresser, massage therapy)

Do you have access to transportation?

Yes
No

How did you hear about our Hospice volunteer program?

Why do you want to be a hospice volunteer?

What qualities (skills, talent, knowledge and experience) do you feel you can incorporate into your hospice volunteer work?

Death & Dying

What are your thoughts and feelings about death?

Have you ever been with someone at the time of their death?

Yes
No

If yes, please describe briefly

Have you ever provided care to anyone who was dying?

Yes
No

If yes, please explain

When thinking of your own death, what words best describe death to you?

Explain

Comments

Code of ethics for volunteers*

As a volunteer, I realize that I am subject to a code of ethics similar to that which binds the professional in the field in which I work. I, like them, assume certain responsibilities and expect to account for what I do in terms of what is expected of me. I understand that any information that is disclosed to me while assisting the Hospice is confidential. I interpret “volunteer” to mean that I have agreed to work without compensation in money. Having been accepted as a volunteer worker, I expect to do my work according to the standards set forth in the Volunteer Policies and Procedures.

Declaration*

I hereby certify that the statements made on this application are true and correct to the best of my knowledge. I understand that, by submitting this application I authorize inquiries to be made concerning my employment, character and public records for the purpose of determining my suitability as a volunteer. I affirm that I have read the Volunteer Code of Ethics and agree to abide by its regulations. I agree to respect the confidentiality of any client information I acquire in the course of my volunteer activities with Hospice.